Obstetrics

Maternal Illnesses in Pregnancy

Dr. Teh
2nd shifting/11.08.08
Juday and forever friends

CARDIOVASCULAR DISEASES 1. Class 1 – Uncompromised

- no limitation of phyicals activity
I. Physiologic Changes During Pregnancy 2. Class 2 – Slightly compromised
1. Increase in cardiac output (30-50%) - (+) symptoms only exists after ordinary physical
2. Increase in blood volume (20-50%) secondary to an activity
increase in aldosterone (Na retention) 3. Classs 3 – Markedly compromised
3. Decrease in peripheral vascular resistance - (+) symptoms occur even with less than ordinary
4. Increase in resting pulse rate (10-15bpm) activty
*do not expect increase blood pressure due to decrease 4. Class 4 – Severely compromised
peripheral vascular resistance - (+) symptoms even at rest

II. Normal ECG Findings Classification of Heart Disease:

1. Slight left axial deviation 1. Valvular Heart Disease
2. Mild ST changes in inferior leads - MS, MR, AS, AR
3. frequent sinus tachycardia 2. Congenital Heart Disease
4. higher incidence of arrythmias - Volume overload (L-R shunt) - VSD, ASD, PDA
- Pressure Overload – PS, coarctation of the aorta
III. Normal PE of the Heart - Cyanotic lesion (R-L shunt) – TOF, Eisenmenger
1. Exaggerated splitting of the first heart sound Syndrome
2. Systolic murmur in 90% 3. Ischemic Heart Disease
4. Arrythmias
IV. Normal CXR Findings
1. Straightening of the upper left border of the heart Risk for Maternal Mortality Caused by Various Heart
2. Horizontal position of the heart Diseases
3. Increase lung markings Group 1 – Minimal Risk (0-1%)
4. Small pleural effusion early postpartum - Eg. VSD, ASD, PDA, PS, corrected TOF,
bioprosthetic valves, Class 1 & 2 MS
V. Normal 2-D Echo Findings Group 2 – Moderate Risk (5-15%)
1. Slight increase in systolic and diastolic LV dimensions - 2A- Class 3 & 4 MS, AS, aortic coarctation
2. Unchanged or slightly improved LV systolic function w/o valvar involvement, uncorrected TOF,
Marfan Syndrome w/ normal aorta, previous
Clinical Indicators of Heart Disease During Pregnancy MI
- 2B- MS w/ artificial valve
I. Symptoms Group 3 – Major Risk (25-50%)
 Progressive dyspnea (secondary to increase - pulmonary hpn, Eisenmengerization, aortic
progesterone) or orthopnea coarctation w/ valvar involvement, Marfan
Syndrome w/ aortic involvement
 Nocturnal cough
 Hemoptysis
MITRAL STENOSIS
 Syncope - ¾ is caused by rheumatic enocarditis
 Chest pain - contracted mitral valves (stiff mitral valves) impedes blood
flow from LA to LVLA dilatation (secondary to increased LA
II. Clinical findings
pressure)pulmonary hpn
 Cyanosis - MR is well tolerated compared to MS
 Clubbing of fingers
 Persistent neck veins MITRAL REGURGITATION or INSUFFICIENCY
 Systolic murmurs grade 3/6 (<3/6 is still normal) - due to decreased systemic vascular resistance
 Presence of diastolic murmurs - heart failure rarely occurs
 Persistent arrythmia (transient is still considered - occasional tachyarrythmias nedd to be treated
normal)
 Persistent split second heart sound Types of Valve Replacements
 Arterial or pulmonary hypertension 1. Mechanical Valve Prosthesis
 Cardiomegaly - may lead to fetal loss, abortion, and embryopathy
- disadvantages: risk of thromboembolism
NYHA (New York Heart Association) Clinical Classification - need for use of anticoagulant=increased risk of
of Heart Disease hemorrhage

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY TLE JAM CECILLE DENESE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI
 Obstetrics
Maternal Illnesses in Pregnancy
Dr. Teh
2nd shifting/11.08.08
Juday and forever friends

- MMR: 3-4%  beta-blocker, digoxin

 anticoagulant (valve replacement)

2. Porcine Tissue Valve

- safer during pregnancy 2. Intrapartum – during labor
- less thrombogenic  avoid excessive pain
- doesn’t need anticoagulant  FHR monitoring
 Avoid hypotension
*stop heparin 6 hrs. before delivery
 Minimize blood loss
Effect of Cardiac Disease on Mother/Fetus
MI During Pregnancy
Increase MMR
- overall MMR 30-50%
IUGR
- women who sustain an infarction <2weeks prior to labor are
Miscarriage
at especially high risk of death
Preterm delivery
- lidocaine to suppress malignant arrythmias
Fetal Death
Malformed fetus (due to medications)
Peripartum Cardiomyopathy
 Development of cardiac failure in the last month of
Effect of Pregnancy in Gravidocardia Patient
pregnancy or w/in 5 months after delivery
- increased workload to the heart – worsening of symptoms
 Absence of an identifiable cause for the cardiac failure
4 Critical Periods of Gravidocardic Patient  Absence of recognizable heart disease prior to the last
1. at 28-32 weeks AOG – max increase in blood volume month of pregnancy
occurs, increase preload  LV systolic dysfunction demonstrated by classic Echo
2. During labor – increase in CO during contration of the criteria such as depressd shortening fraction or ejection
uterus fraction
i. Pain & anxiety – 5-60% increase in CO due to
increase sympathetic stimulation RESPIRATORY DISEASES IN PREGNANCY
ii. Squeezing of blood from the uterus I. Physiologic Changes
3. Delivery – increase CO (60-80%) 1. diaphragm rises about 4 cm
4. one week post partum 2. subcostal angle widens
3. transverse diameter of thoracic cage increases by
Labor and Delivery about 2cm
- Vaginal delivery is the preferred route (assisted vaginal 4. thoracic circumference increases about 6cm
delivery either by forceps or vacuum) 5. changes in pulmonary function
- CS delivery is limited to OB indications II. Changes in Pulmonary Function
- Hypotension should be avoided 1. ↑ Vital capacity by 100-200cc
2. ↑ Inspiratory capacity by 300cc
Epidural Anesthesia is the anesthesia of choice 3. ↑ Tidal volume
4. ↑ Minute ventilation rate by 40% from 7-10.5%
AHA (1997) Guidelines for Bacterial Endocarditis 5. ↓ Expiratory reserve volume from 1,300 to 1,100cc
Prophylaixs
6. ↓ Residual Volume from 1500-1200cc
 High risk patients
7. ↓ Functional residual capacity
- IV or IM ampicillin 2g + gentamicin 1.5mg/kg w/in 30
mins or before the procedure, then ampicillin 1g q6 - results to increase ventilation due to deeper but more
- if allergic to penicillin, IV vancomycin 1g over 1-2 hrs frequent breathing
+ gentamicin - induced by increased basal O2 consumption (20-40
 Moderate risk patients ml/min) in the 2nd half of pregnancyfall in arterial pO2 to
- oral amoxicillin 2g p.o. 1 hr before the procedure or 28mmHg
IV ampicillin 2g w/in 30 minutes prior to procedure - slightly alkalotic plasma pH at 7.45
- decrease in HCO3 to 20 mEq/L
Management
1. Antepartum – before labor Dyspnea During Pregnancy
 limit physical activity  Due to alveolar hyperventilation
 fluid restriction  A response to substantially low pCO2 due to anatomical
 correct anemia changes in the thorax
Pneumonia
MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY TLE JAM CECILLE DENESE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI
 Obstetrics
Maternal Illnesses in Pregnancy
Dr. Teh
2nd shifting/11.08.08
Juday and forever friends

BACTERIAL PNEUMONIA  with severe asthma at start of pregnancy more likely to

 Secondary to aspiration of nasopharyngeal secretions experience worsening disease
 Organisms: S. pneumoniae, H. influenzae, mycoplasma  18x ↑ exacerbation following CS delivery compared with
 Symptoms: fever, productive cough, chest pain, dyspnea, vaginal (choice of delivery)
pleuritic chest pain
 Laboratory: (+) mild leukocytosis, Gram stain of sputum Effects on Pregnancy
 Mangaement: antimicrobial treatment is empirical  risk of preeclampsia, PTL, LBW and perinatal mortality
- Erythormycin (pneumococci, mycoplasma, chlamydia)  maternal deaths from status asthmaticus
- Cefotaxime or ceftriaxone (staph, haemophlius)  life threatening complications: pneumothorax, cardiac
 Clinical improvement evident in 48-72 hrs, reduction of arrythmia, muscle fatigue with respiratory arrest
fever I 2-4 days  maternal alkalosis leading to fetal hypoxemia
 Effect on pregnancy: MMR=1.6%, PMR=2.2%
Diagnosis of Asthma
Factors that Increase the Risk of Death or Complication  ABGs
with CAP  FEV1 (1 sec from max expiration) – single best measure
1. Coexisting chronic condition to reflect severity of disease
2. Clinical findings
 RR: 30/min Management of Acute Asthma
 Hypotension  IV hydration
 PR > 125 bpm  Supplementation O2 by mask after ABG extraction
 Hypothermia <30OC  Baseline FEV1 or PEFR
 Altered mental status  Continuous O2 pulse oximetry and ext. fetal monitoring
 Extrapulmonary disease  Pharmacologic treatment (B-agonist, EPI)
3. Laboratory findings  Corticosteroid be given early to all patients
 Leucopenia (<4000/υL) or leukocytosis (>20,000/ (hydrocortisone)
υL) *if initial treatment with B-agonist results to PEFR>70% of
 pCO2 (60mmHg) or CO2 retention baseline=DISCHARGE!!
 Increase serum urea
 Evidence of sepsis or organ dysfunction Status Asthmaticus
4. CXR findings  Managed in ICU
 1 lobe involvement cavitation or pleural effusion  Early intubation is considered when maternal respiratory
status continues to decline despite aggressive treatment
VIRAL PNEUMONIA (INFLUENZA, VARICELLA)
 Effect to baby Indication for intubation
a. 3x risk of NTD (neural tube defects like anencephaly,  Fatigue
spina bifida) of women with influenza early in  CO retention
pregnancy due to hyperthermia  Hypoxemia
b. serious infection with varisella in asso with preterm
delivery. if infection occurs before 20th AOG, fetus can Management of Labor and Delivery
be infected and permanent sequelae results  Stress-dose corticosteroids are given to any patient given
 Treatment systemic steroid treatment w/in preceding 4 weeks
Influenza – amantadine or rimantidine 200mg OD  Fentanyl is preferred analgesic than meperidine and
- prevent with vaccination after the 1st trimester morphine
Varicella – acyclovir 10mg/kg  Epidural anesthesia for labor is ideal
- VZIG 125 units/10kg IM should be given w/in 96 hrs  For CS, continuous conduction analgesia
from infection (max dose 625 units)  PGE2 instead of PGF2 for refractory post partum
- vaccine is contraindicated in pregnancy hemorrhage

Bronchial Asthma Tuberculosis in Pregnancy

Pathophysiology: Effects on pregnancy
Bronchial smooth muscle contraction, mucus hypersecretion,  Incidence of pretem labor, LBW, IUGR
mucosal edema  6x increase in perinatal mortality rate
Effects of Pregnancy on Asthma Treatment
 1/3 improved, 1/3 unchanged, 1/3 worsen
MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY TLE JAM CECILLE DENESE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI
 Obstetrics
Maternal Illnesses in Pregnancy
Dr. Teh
2nd shifting/11.08.08
Juday and forever friends

 INH 5mg/kg/day (not>300mg) + vit B6 50mg OD

 Rifampicin 10 mg/kg/day (not>2.5g OD) Thyrotoxicosis in Pregnancy
 Ethambutol 5-25mg/kg/day (not>2.5g OD) - occur in about 2 out of 1000 pregnancies
- most common causes:
Neonatal TB is Fatal • Grave’s disease (90-95%)
Aquired thru: • Gestational trophoblastic neoplasia
 Infected placenta • Toxic multinodular goiter
 Hematogenously • Toxic adenoma
 Aspiration of infected secretions at delivery 50% occur • Hyperenuresis gravidarum
if mother with active infection is not treated
Therapy
When to suspect TB  Limited to anti-thyroid drugs or surgery
A. Physical Exam  Radioactive iodine is an absolute contraindication
B. Diagnostic Exam - Cause destruction of fetal thyroid
1. sputum exam smear – more specific than CXR - Caution against pregnancy = 1year after
2. CXR treatment
3. culture – definitve diagnosis
 Therapeutic gain is to achieve a euthyroid or a slightly
a. culture media – identification in 4-6 weeks
hyperthyroid mother to prevent hypo- or
b. BACTEC 460 method – identification in 2-3
hyperthyroidism
weeks
Anti-thyroid Drugs
A. Thionamide (PTU and methimazole)
Indications for the Various Microbiological Tests:
- Synthesis of T4 to T3 in peripheral tissues
1. AFB smear – for all suspected TB cases
- Crosses the placenta 4x less and breastmilk 10x less
2. Mtb culture – for smear (-) patients w/symptoms highly
than methimazole
suggestive of PTB and suggestive CXR
B. Iodides
3. Mtb culture and drug sensitivity
- Decrease serum T3 and T4 by 30-50% in 10 days by
a. smear (+) or (-) patients suspected of MDRTB
enabling the release of stored thyroid hormones
(multidrug-resistant TB)
- Readily crosses the placenta and breastmilk
b. smear (+) patients w/ fall or rise phenomenon
- Dosage: 5-10g BID
c. all cases of relapse
C. Beta blockers
d. all active cases previously treated for >3 months
- Control of adrenergic symptoms of thyrotoxicosis
e. all cases of treatment failure
- Propranolo 20-40mg BID or Atenolol 50-100mg daily
- Side effects: IUGR, decrese in placental size, fetal
THYROID PHYSIOLOGY DURING PREGNANCY
bradycardia & hypoglycemia
1. Anatomically (+) moderate thyroid enlargement
(glandular hyperplasia and increase vascularity)
Effects on Pregnancy
2. Histologically (+) active formation and secretion of
thyroid hormones  Depend on whether metabolic control is achieved
3. Increase radioactive iodine by thyroid gland  Increse incidence of pre-eclampsa and heart failure
4. Start of 2nd month: total serum T3 and T4  Adverse perinatal outcomes for untreated women
concentration increase sharply  Perinatal Mortality Rate = 8%
5. Daily T4 secretion is increased  Fetal Mortality Rate = 12%
6. TBG (thyroid binding globulin) – due to estrogen effect Effect on Neonate
7. NO effect on TRH level  Transient thyrotoxicosis
8. TSH unchanged – doe not cross placenta  With long-standing in utero exposure to treatment
9. Normal FT3 and FT4 levels  Neonatal hypothyroidism
 Goiter
Signs and Symptoms of Hyperthyroidism  No adverse effect in subsequent growth and development
 Tachycardia
 Abnormally high sleeping pulse rate Thyroid Storm/Heart Failure
 Thyromegaly  PTU 1g PO or crushed thru NGT; after 1 hr give iodide q8
 Exophthalmos  SSKI 5g or Lugol’s sol’n 10g
 Failure to gain weight  Dexamethasone 2mg IV q6 for 4 doses
 IV beta-blocker if without heart failure
Diagnosis
Elevated free T4 and low TSH
MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY TLE JAM CECILLE DENESE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI
 Obstetrics
Maternal Illnesses in Pregnancy
Dr. Teh
2nd shifting/11.08.08
Juday and forever friends

Hypothyroidism  Women with marked obesity

 Uncommon in pregnancy  Strong family history
 May cause mental retardation, low IQ, cretinism
Classification of Pregnant Diabetic
DIABETES MELLITUS Class
Glucose Metabolism During Pregnancy A1 GDM FBS 2OPP <120 mg/dl diet
3rd trimester = increase insulin resistance (skeletal and liver) <105 mg/dl
due to: A2 GDM FBS 2OPP >120 mg/dl insulin
 Human Chorionic Somatomammotropin (hCS) >105 mg/dl
 Human placental growth factor B >20 y/o <10 yrs duration <10 years
 Cortisol duration
 Progesterone C 10-19 y/o 10-19 yrs 10-19 yrs
 Estrogen duration duration
- These hormones stimulate beta cells of pancreas to D <10 y/o >20 yrs duration >20 yrs duration
secrete insulin (cause hypertrophy and hyperplasia Effects of GDM
of beta cells) GDM class A2 is associated with unexplained stillbirth ADA
- Increase plasma glucose, free fatty acids, insulin (1999): FBS > 105 mg/dl during last 4-8 weeks; AOG is
secretion, amino acids associated with increase risk of fetal death
*Accelerated starvation in pregnancy is due to continuous
withdrawal of nutrients by the fetus; occurs within 14-18 hrs in Maternal Effects
pregnancy (N=2-3 days)  Increase frequency of hypertension and need for CS
delivery
GDM (Gestational Diabetes Mellitus)  >1/2 ultimately develop overt DM in 20 years
 Carbohydrate intolerance of variable severity w/onset or
first recognized during pregnancy Fetal Effects
 Implies: induced by pregnancy, DMII unmasked or  Increased risk of macrosomia/excessive growth
discovered during pregnancy  Risk of shoulder dystocia
 Increase chance of obesity and DM
Screening Test
 50 g OGCT (oral glucose challenge test) Management
 done between 24-28 weeks AOG (Carpenter and Coustan)  FBS>105 mg/dl or 2-hr PP glucose >120 mg/dl – insulin
highest sensitivity within this period  FBS should be kept < or equal to 95 mg/dl
 >140 mg/dl (identifies 80%)  6-12 weeks after delivery: 75g OGTT
• if FBS >140 mg/dl or 2-hr PPG >200 md/dl  (+)
Diagnostic/Confirmatory Test DM
100 g OGTT (oral glucose tolerance test) with 2 abnormal • if FBS <140 mg/dl or 2-hr PPG 140-200 mg/dl 
values to confirm
impaired glucose tolerance
OGTT 75 g OGTT Carpenter O’Sullivan NDDG
• if normal 75g OGTT
mmol/L WHO/ASGO and and (1979)
- reassess at a min of 3 yr interval elevated FBS
(mg/dl) DIP Coustan Mahan
during pregnancy
FBS 5.8 (98) 5.3 (95) 5 (90) 5.8 (105)
- DM more likely to persist post partum
1 hr 10.6 (190) 10 (180) 9.2 (90) 10.6 (190)
2 hr 7.8 (140) 8.6 (155) 8.1 (145) 9.2 (165) Overt DM – random BS >200 mg/dl; FBS >126 mg/dl + 3 P’s
3 hr 7.8 (140) 6.9 (125) 8.1 (145) w/unexplained weight loss
4th International Workshop conference on GDM
Recommendation Fetal Effects
A. Low risk 1. Abortion especially in HbA1c >12% or preprandial
 Member of ethnic group with low prevalence >120 mg/dl
 No known 1st degree relative with DM 2. Preterm
 <25 y/o 3. Malformation (muskuloskeletal-10%, cardiac
 normal weight before pregnancy anomalies 38%)
 no history of abnormal glucose metabolism 4. Unexplained stillbirth
 no history of poor OB outcome 5. Hydrmnios (AFI >24 cm or vertical pocket 8cm)
B. Average risk
 Hispanic, African, Asian, Native Americans Neonatal Effects
MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY TLE JAM CECILLE DENESE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI
 Obstetrics
Maternal Illnesses in Pregnancy
Dr. Teh
2nd shifting/11.08.08
Juday and forever friends

1. RDS
2. hypoglycemia
3. Hypocalcemia <7mg/dl
4. Hyperbilirubinemia
5. Cardiac hypertrophy
6. Inheritance of DM
7. Altered fetal growth

Hi classmates!! Para maiba, maliit na space lagyan ng filler!!

Hehehe..pacheck po kung tama un diagnostic/confirmatory
test(100gOGTT) kasi hindi ko nakuha lahat eh..galing po yan
iba’t ibang sources..hehehe..;p
Salamat!!=)

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY TLE JAM CECILLE DENESE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI